This week I reviewed Washington State Nursing Care Quality Assurance Commission records for Kimberly Hiatt—the 1,500 pages allowed under public disclosure. I had requested these records in order to look at the primary sources unfiltered by journalists or people close to the case. I also requested them as data for a journal article I am preparing on health workforce regulatory systems. Kim’s story continues to disturb me. I won’t repeat her story here, since it has been told in many other places (and most completely/accurately in my opinion by JoNel Aleccia/MSNBC). Instead, I will share my main impressions, thoughts, and unanswered questions.

My overarching impression is that the entire cascade of events contributing to Kim’s suicide could have been prevented. A secondary impression is just how complex our health care system is—how prone to errors of all sorts, not just medical errors, but errors of judgment by people in various levels of the healthcare hierarchy. It is not any one person’s—or one institution’s—fault. However, all along the way, individuals with power could have significantly altered the course for Kim. And nurses were turning on other nurses within this cascade of events. Not only nurse administrators, but also nurse colleagues of Kim’s. (I should note that there were also nurse colleagues who were quite supportive of Kim–and these show up in the record as well.)

But some of Kim’s colleagues were making unsubstantiated accusations, including a sophomoric and trumped-up sexual harassment charge by seemingly homophobic co-workers (and from the record, not handled well by hospital HR). This sexual harassment charge by a female nurse against Kim involved the fact that Kim was openly gay. That this could happen in a modern-day US hospital is dismaying. That this could happen in a US hospital in a city with the highest per capita population of lesbian-identified women is appalling. Then there was the more recent charge (by an ICU nurse) of Kim abandoning a patient. An investigation of this charge found that physicians had called Kim into help with a difficult parent conference, and Kim had arranged coverage for her patient.

Nurses could have prevented the negative outcome: shame on us.

Kim had worked at Seattle Children’s Hospital for 24 years on several different units. This was her first major medical error. The Cardiac Intensive Care Unit where Kim worked had just offered her a permanent position. Her last performance review dated 8-24-10 signed by the Director of ICU rated Kim’s performance as a 4/5 “Leading Performer.” Annual job performance reviews going back to 1994 are similarly high, with a peer writing, “Without a doubt, Kim is one of the most skilled nurses on our ICU.” Then, immediately after the medication error, in a report to the Nursing Commission, this same Director of the ICU (and a nurse herself) expressed concerns about Kim’s nursing practice—that she “failed to partner with leadership and work to correct the situation that could have caused her to make the failure.” Kim had immediately reported her medication error—had helped the medical staff remedy the situation—had disclosed her error to the baby’s parents with the support of the lead physician—then had been escorted off hospital property/put on administrative leave, and soon after was fired. Where exactly was Kim’s failure to partner with hospital leadership?

The initial report of an adverse event sent from Children’s hospital to the Nursing Commission stated: “an overdose of medication to an infant, who died as a result” even though it was not clear (and remains unclear according to the medical examiner’s final report) that the overdose contributed to the baby’s death. It was also reported this way in a memo by the CEO of Children’s hospital—that was then picked up by KOMO News and the Seattle Times. Guilty until proven innocent. The Nursing Commission member’s e-mails/memos acknowledge this “heavy media attention” as pressuring them to make Kim’s ‘case’ high priority. How might this have prejudiced the Nursing Commission’s decision-making process for Kim? The Nursing Commission member in charge of Kim’s investigation is herself a Chief Nursing Officer of a hospital. How might that lens have affected the Nursing Commission’s decision-making process for Kim?

The Nursing Commission refused Kim’s lawyer’s repeated requests for copies of their complete investigative materials—including the final medical examiner’s report—so that he could adequately advise Kim on her options before she was required to sign the final Stipulation of Informal Disposition (the final disciplinary action/sanctions). Why was his request denied?

The Stipulation sanctions included a $3,000 fine, 48-month probationary period where Kim needed supervision for giving medications, Commission approval of any future jobs, and reporting of her discipline to the National Practitioner Databank—as well as made public on the Department of Health website. The Department of Health staff attorney assigned to this case wrote in an internal e-mail “Talking Points” prior to the final settlement, “Tell (Kim’s lawyer) his client may take it or leave it…” Kim signed this Stipulation. A week later she killed herself. Upon being notified of her death, the Staff Attorney for the Nursing Commission advised closing Kim’s case as “a unique closure.” As of today, Kimberly Hiatt shows up in the Washington State Provider Credential Search Database as having an expired nursing license and having had no disciplinary actions.

What does all of this say about the deficits in our health care system? What can nurses—and others—do to prevent this sort of treatment of a nurse? Can anything be done to reform the health professions regulatory system? Can anything be done to hold hospitals accountable for their treatment of nurses?

I realize that it is easy for me to say that nurses need to speak up more about injustices to other nurses, to stop petty in-fighting and not so petty back-stabbing. I am–as spokespersons for Children’s hospital refer to us–an “armchair safety expert who doesn’t know the details of Hiatt’s case.” Except I do know 1,500 pages of details of Hiatt’s case. It now makes less sense to me than it did before. There is no suitable closure–not even a unique closure–for Kim Hiatt’s case.